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The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is an appropriate finger food?
- A. Hot dog pieces
- B. Sliced bananas
- C. Whole grapes
- D. Popcorn
Correct Answer: B
Rationale: Sliced bananas. Finger foods should be bite-size pieces of soft food such as bananas. Hot dogs and grapes can accidentally be swallowed whole and-mile occlude the airway. Popcorn is too difficult to chew at this age and can irritate the airway if swallowed.
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A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack?
- A. Cheese crackers
- B. Peanut butter sandwich
- C. Potato chips
- D. Vanilla cookies
Correct Answer: C
Rationale: Children with celiac disease should eat a gluten free diet. Potato chips are naturally gluten-free, unlike the other options which contain wheat-based ingredients.
The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
- A. Epistaxis
- B. Abdominal distention
- C. Nausea
- D. Hyperactivity
Correct Answer: A
Rationale: Clopidogrel is an antiplatelet medication that can increase the risk of bleeding, such as epistaxis (nosebleeds). Abdominal distention, nausea, and hyperactivity are not typical adverse effects of clopidogrel, so answers B, C, and D are incorrect.
The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding, the nurse should plan to
- A. restrict visitors to immediate family
- B. avoid arousal of the client except for family visits
- C. keep client's hips flexed at no less than 90 degrees
- D. apply a warming blanket for temperatures of 98 degrees Fahrenheit or less
Correct Answer: A
Rationale: restrict visitors to immediate family. Maintaining a quiet environment will assist in minimizing cerebral rebleeding. When family visit, the client should not be disturbed. If the client is awake, topics of a general nature are better choices for discussion than topics that result in emotional or physiological stimulation.
The nurse is caring for a client with a history of irritable bowel syndrome.
- A. Which dietary instruction is most appropriate for a client with irritable bowel syndrome?
- B. Avoid caffeine and alcohol.
- C. Eat large, infrequent meals.
- D. Consume a high-fat diet.
- E. Limit fiber intake.
Correct Answer: A
Rationale: Avoiding caffeine and alcohol reduces gut irritation in irritable bowel syndrome. Small, frequent meals, balanced fiber, and low-fat diets are recommended.
A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
- A. Has increased airway obstruction
- B. Has improved airway obstruction
- C. Needs to be suctioned
- D. Exhibits hyperventilation
Correct Answer: A
Rationale: Has increased airway obstruction. The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened.